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Journal of Religion, Spirituality & Aging, 25:216–237, 2013Copyright © Taylor & Francis Group, LLCISSN: 1552-8030 print/1552-8049 onlineDOI: 10.1080/15528030.2012.741562

Training and Sustaining: A Model for VolunteerSpiritual Care Visitors in Long-Term Care

LUCINDA LANDAUSt. Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada

KEVIN BRAZILQueen’s University Belfast, Belfast, United Kingdom

SHARON KAASALAINEN and DIANE CRAWSHAWMcMaster University, Hamilton, Ontario, Canada

Volunteer provision of spiritual care in an Ontario, Canada,long-term care home was the focus of a case study regarding resi-dent spiritual care needs in a municipal environment that does notfund professional chaplains. Scope of practice issues, spiritual careskills in long-term care, and diversity sensitivity were identified askey areas for volunteer education. Volunteer training modules weredesigned using Theological Reflection as the theoretical frameworkfor spiritual care provision. An innovative model for sustainablespiritual care provision in long-term care is proposed, which reliesupon leadership from a professional chaplain (staff or volunteer).

KEYWORDS spiritual care, chaplain, volunteer training,Theological Reflection, long-term care

BACKGROUND

The delivery of spiritual care in long-term care is an important aspect of over-all care and many institutions are still struggling with how to meet residentneeds. This research explores issues of concern to professional chaplains,what happens when volunteers are the default spiritual care providers andhow best to provide the kind of sustainable spiritual care that long-termcare residents are seeking. In this context, it is understood that the practice

Address correspondence to Lucinda Landau, 1 Haines Avenue, Dundas, Ontario L9H 5J9,Canada. E-mail: [email protected]

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Training and Sustaining 217

of professional spiritual care brings together compassionate client-centeredcare, a mastery of divinity perspectives, and cultural sensitivity with psy-chotherapeutic insight to meet a client’s therapeutically assessed need forcounseling, discernment, sacred expression (prayer, ritual), religious andemotional support.

A gap between the theory and practice of spiritual care was identifiedin a Southern Ontario municipally funded long-term care home during theinitial environmental scan of the Quality Palliative Care in Long Term Careresearch alliance. Stakeholder interviews revealed concerns over the munic-ipality’s reliance upon volunteer spiritual care, provision, scope of practiceissues for volunteers, volunteer perception of gaps in spiritual care and con-cern regarding proselytizing with residents. Also, the home is located in anarea that has experienced rapid population growth, with a marked increasein visible minority demographics.

Quality Palliative Care in Long Term Care is a five-year comparativecase study research involving four long-term care homes in Ontario, Canada,funded by the Canadian Social Sciences and Humanities Research Councilthrough the Community University Research Alliance Program. The cen-tral aim is to improve the quality of life of residents in long-term carehomes, through the development of resources and palliative care pro-grams. The Southern Ontario study site home, while well respected for careprovided, is situated in a municipality that will not fund a professional chap-lain. Community support is strong and spiritual care is delivered throughvolunteers and area clergy.

Aging Population in Long-Term Care and Need for Spiritual Care

Current research reveals that residents of long-term care facilities are present-ing with an increasing complexity of care and an average life expectancy ofthree to five years (Moser et al., 2003). Residents are generally considered“older, sicker and with more complex care needs” than before (OANHSSReport, 2010, p. 11). Many homes do not adequately meet the needs ofdying residents and their families (Wetle, Teno, Shield, Welch, & Miller,2004) and little is known about spiritual care as part of interdisciplinarycare in long-term care (Hamilton, Daaleman, Williams, & Zimmerman, 2009).Interdisciplinary care in long-term care has demonstrated better outcomes forresidents, but chaplains are generally missing from the list of professionalsworking in the field (OANHSS Report, 2010). If, as reported by Shield et al.(2004), one in four Americans are dying in nursing homes, then there is agap in care regarding the spiritual needs of residents (Edwards, Pang, Shiu,& Chan, 2010).

Nonetheless, a link between spirituality, aging, and palliative care isaffirmed in the research (Mowat et al., 2010; Marsten, 2010; Edwards et al.,2010; Bushfield, 2010; Netting, 2010; Goodall, 2009; Stranahan, 2008). The

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provision of spiritual care is especially important for older adults living inlong-term care as they deal with end of life issues (Luff, Ferreira, & Meyer,2011; Sinclair, 2011; Edwards et al., 2010; Jolley et al., 2010; Marsten, 2010;Hamilton et al., 2009). The hospice model of palliative care reveals the effec-tiveness of chaplains in creating meaning for the dying and finding hope inthe face of death (Nolan, 2011; Coates, 2010).

Spirituality and meaning-making are considered integral to the majordevelopmental tasks common in older adults. In a United Kingdom researchstudy on spiritual care with dementia residents, Margaret Goodall (2009)found that by designing person-centered interventions that highlightedreflection, relationship, and restoration, they were also meeting the spiritualneeds of residents. Studies on the effect of religion on health and coping withlife changes acknowledge that religious practice is an important factor thatmust be taken into account for assessment and treatment and may enhanceresponse to psychotherapy (Koenig, 2009; Wink & Scott, 2005; Pargament,Koenig, & Perez, 2002). Spiritual well-being is now readily acknowledgedas an important component of palliative and end-of-life care, with growingattention to issues of cultural diversity (Green, 2009; Puchalski et al., 2009;Bosma, Apland, & Kazanjian, 2008; Heidrich, 2007; Kemp, 2007; Brietbart,2002). Spiritual care provision, as a distinct professional practice, can addressclient need to explore religious, spiritual, and existential issues in multiplesettings, most notably in long-term care.

Professional Chaplaincy and Delivery of Spiritual Care

Recognition of spiritual care as an element of whole person care hasincreased alongside a societal shift in understanding how spirituality differsfrom religion (Puchalski et al., 2009). The interdisciplinary health care field ismuch attracted to the provision of spiritual care and professional disciplinesare examining ways in which spiritual care can be incorporated within theirpractice competencies. Social workers, nurses, and physicians are increas-ingly publishing on this topic (Saguil, Fitzpatrick, & Clark, 2011; Burkhart,Schmidt, & Hogan, 2011; Hodge & Horvath, 2011; Baldacchino, 2011; Bursell& Mayers, 2010; Puchalski et al., 2009; Weaver, Koenig, & Flannelly, 2008).The focus is often on creating tools for spiritual care assessments and findinggood role models for spiritual care delivery.

However, there are important theoretical, educational, regulatory andscope of practice considerations regarding the provision of spiritual carein a professional context (Nolan, 2011; Mowat et al., 2010; Pesut, Reimer-Kirkham, Sawatzky, Woodland, & Peverall, 2012; Brown, 2010; Kelly, 2010;Carey & Devoren, 2008; Atchley, 2008; Austin, 2006; VandeCreek & Burton,2001). In most jurisdictions, chaplains or professional spiritual care providershave earned a Master of Divinity or its equivalent before registering forchaplaincy training. While many clergy may receive basic chaplaincy training,


professional chaplaincy requires extensive clinical instruction. The profes-sional chaplain is educated to meet both spiritual and religious needs aspart of a relationship-based, whole person care model (Emanuel & Handzo,2012). Contemporary chaplains also have instruction regarding cultural diver-sity, multi-faith and secular perspectives. There is a role for chaplains to leadprovision of spiritual care for the interdisciplinary team and in volunteereducation and management.

Spiritual care is practiced in distinct settings including prison ministry,military chaplaincy, and in clinical locations such as acute care hospitals,hospice, and long-term care homes. The professional training for prison,military, or “clinical” chaplains is the same and relies upon clinical pastoraleducation. Members of the Canadian Association for Spiritual Care (CanadianAssociation for Spiritual Care, 2012b) receive training in psychotherapeu-tic interventions. In some Canadian provinces, regulatory bodies recognizechaplains/spiritual care providers as psychotherapists. Being a professionalchaplain or spiritual care provider creates a different relationship as opposedto other health care providers simply because the framework of profes-sional spiritual care competencies incorporates the prophetic, the practiceof reverence, the education and skill to discuss theological issues alongsidepsychotherapeutic modalities.

At the core of spiritual care provision is the creation of genuine trustrelationships that help clients face life-changing events by discerning theirpractical and internal resources. The dynamic of spiritual care provisionis in a dialogical process rooted in Theological Reflection as a theoreticalframework.

Naturally occurring psychological processes such as end-of-life reviewis enriched by the meaning-making process integral to spiritual care (Butler,1963, 1980 in Le Favi & Wessels, 2003). Peter VanKatwyk’s (2003) integrativeperspective on “reconstructive communication” suggests that by joining oth-ers in a meaning-making process of understanding, new ways of interpretingour experience can emerge; this may include elements of prophetic min-istry. Spiritual care has its roots in hermeneutics, the study of biblicaltexts. In spiritual care, we are all considered as “living human documents”(Boisen, 1936 in O’Connor, 1998, p. 2), full of elements of grace and flaws,open to interpretation. Using a hermeneutical method of theological inquiryin relation to person-centered care generates the potential for individualtransformation.

The role of the professional chaplain is not to represent any one par-ticular set of beliefs, but to be present in relationship, to allow the clientto explore their concerns and to assess and provide therapeutic spiritualcare interventions as needed (Coates, 2010; Bodde, 2008). This perspectiveis a unique aid for communities where demographic change has added alevel of complexity in providing whole person care for minority groups.Being professionally conversant with multiple divinity perspectives, that is,


religious and spiritual outlooks, but not religious and secular outlooks isintegral to a chaplain’s practice because a client’s belief systems, personalnarrative, and culture will inform the spiritual care assessment and therapeu-tic interventions. Allied health professionals rarely have this level of expertiseand professional chaplains should be consulted when making assessmentswithin the spiritual care domain. Long-term care homes without a profes-sional chaplain are missing an important element in one-on-one care andsupportive community life that effective spiritual care can create.

In general, the theoretical framework for spiritual care is not wellunderstood among health care professionals and administrators of healthcare facilities immersed in the clinical enterprise of evidence-based care(Berlinger, 2008; deVries, Berlinger, & Cadge, 2008; Jacobs, 2008; Mohrmann,2008; Smith, 2008). At issue is a genuine understanding of the syncreticaspect of professional spiritual care practice that brings together elementsof sacred expression with theoretically grounded therapeutic interventions.Chaplaincy is increasingly claiming the psychotherapeutic role as integralto our professional competencies; this may be a change for administratorsused to seeing spiritual care providers as limited to religious support forpatients and clients. As such, a comprehensive description of the evolu-tion of Theological Reflection in spiritual care provision is included in themethodology of this research.

THEORETICAL FRAMEWORK: THEOLOGICAL REFLECTIONIN PROFESSIONAL SPIRITUAL CARE

Spiritual Care/Chaplaincy as a professional discipline is rooted in the sem-inal work of theologian Anton Boisen (1876–1965). In the 1920s, his workof challenging seminarians to explore their study of the human experienceby thinking theologically represents the beginning of Supervised PastoralEducation (Leas, 2012). Supervised Pastoral Education is the widely adaptedmodel for didactic instruction and clinical training of professional chaplainsand pastoral counselors (Canadian Association for Spiritual Care, 2012a; TheAssociation for Clinical Pastoral Education, 2012; Association of ProfessionalChaplains, 2012; National Association of Catholic Chaplains, 2012; NationalAssociation of Jewish Chaplains, 2012).

As a theologian, Boisen was concerned that theology must correlatewith lived experience. He drew upon the ideas of Friedrich Schleiermacher,a late eighteenth-century theologian regarded as the founder of PracticalTheology and modern hermeneutics (Osmer, 2008). By using theology inthe listening to and telling of the client’s story, Boisen saw therapeutic bene-fit. Both client and chaplain are seen, in Boisen’s language, as texts or “livinghuman documents” (Boisen, 1936 in O’Connor, 1998, p. 2), akin to the Bibleand open to interpretation. He envisioned the provision of spiritual care as


a therapeutic process, amalgamating the care of both acute mental healthand spiritual difficulties into a theological methodology by conceptualizingthe person as text, equally imbued with sin and grace. Boisen believed thatthe care of the soul can begin in a traumatic event and he pioneered “nar-rative therapy” as a kind of therapeutic “God-talk” (Leas, 2012). An earlyproponent of what evolved into case study methodology, Boisen educatedclergy for pastoral ministry through the analysis of case records of psychiatricpatients to understand the religious meanings of mental illness (VanKatwyk,2003).

This framework helped to shape the Supervised Pastoral Educationstreams of Clinical Pastoral Education and Pastoral Counseling Educationas an experiential adult-learning model for professional practice. Althoughinitially founded on Christian theology, Supervised Pastoral Educationis actively inclusive of diverse religious, spiritual, cultural, and genderidentities. Professional chaplains and pastoral counselors must have theirown formalized faith affiliation but they may or may not be ordained.They maintain unconditional positive regard for the personal views oftheir clients, including individuals who hold religious, spiritual, or secularperspectives.

Supervised Pastoral Education is a syncretic melding of didactic andsupervised clinical work covering the span of theological, psychother-apeutic, social sciences, ethical, and interdisciplinary models. In short,Supervised Pastoral Education is a formalized application of practicaltheology (O’Connor, 1998). Contrasting with academic or fundamental theol-ogy and church-rooted systematic theology, practical theology deals withthe praxis of ministry. The emphasis is on transformation as the resultof critical reflection upon the intersections between theory and ministrypractice.

Theological Reflection is a distinct element of professional self-reflectionin the ethical practice of spiritual care. The narrative thread of inquirywithin theological reflection aspires to articulate an alternate vision of real-ity within the story told by the “other.” Both the client and care providercan be enriched through the therapeutic relationship as self-reflection onthe ministry encounter is open to transformative new insights (Aten &Leach, 2009; Williams, Teasdale, Segal, & Kabat-Zim, 2007; Pargament,2007).

The incarnational theology of chaplain and Clinical Pastoral Educationinstructor Charles Gerkin (1989) incorporates Hans-Georg Gadamer’s philo-sophical hermeneutics (1975) as a central dynamic in the praxis of spiritualcare (O’Connor, 1998). Praxis incorporates the idea that spiritual care isimbued with meaning, not just applied theory. Taking Gadamer’s metaphorof “horizon of meaning,” Gerkin’s understanding of practical theology inte-grated the dialogical interchange between client and caregiver as a fusionof horizons that yields new meanings. He sculpted deeper significance


from Boisen’s understanding of the living human document to extrapo-late that the spiritual care conversation is imbued with theological meaningand open to interpretation. Gerkin evolves Paul Ricoeur’s hermeneutic ofunderstanding/explaining/understanding as an instrument to fathom min-istry practice into praxis/theory/praxis (O’Connor, 1998). The goal is totransform the encounter into a new praxis.

Using transformative Theological Reflection as a theoretical frameworkfor qualitative investigation is becoming established in spiritual care research.A recent study by Harriet Mowat et al. (2010) used this same methodologyto explore a group approach for chaplains working to provide effective spir-itual care for older people. By integrating Gadamer’s fusion of horizons withGerkin’s work on reflective tasks (1989), Mowat determined that a major taskfor chaplaincy is to help older individuals in their adaptive processes throughfocus on the underlying meaning of their life journey.

This informs a growing consensus that for the aging population, forthose suffering from dementia and for those living in long-term care, theprovision of spiritual care is relationship based (Mowat et al., 2010: Edwardset al., 2010; Goodall, 2009). The hermeneutics of ministry praxis and transfor-mative Theological Reflection addresses the relational stance of spiritual careprovision with older individuals and professional chaplains are best trainedto provide that care.

METHODOLOGY

Design

This research incorporated case study methodology that is considered appro-priate for investigations in long-term care (Luff et al., 2011; Moriarty, 2011). L.Brown (2010) affirms the common usage of case study in chaplaincy researchas a means to strengthen professional practice, to connect theory with the-ology and facilitate the development of models that show the efficacy ofspiritual care. Several authors advocate case study research in chaplaincy todemonstrate how spiritual care can make a difference in health-care settingsand as a means to connect with other health-care professionals (Fitchett,2011; O’Connor, 2006; O’Connor & Meakes, 1998).

This study involved three distinct phases of investigation in one facility;the long-term care home was considered as the unit of analysis. Undergirdedby the theological framework for spiritual care, the capacity developmentprocess involved sequential steps, which focused on the following:

● Stakeholder focus group and thematic analysis of central concerns;● Scope of practice and regulatory concerns for spiritual care volunteers; and● Training of long-term care volunteers in spiritual caregiving skills and

diversity sensitivity.


Setting

The study site for this research was an accredited long-term care homewith 200 beds, providing permanent working teams with around-the-clocknursing and medical services, and social, therapeutic, and nutritional careto residents in a town with a population of less than 100,000. The home isfunded by the municipality and spiritual care is provided by volunteers andarea clergy.

The town has recently undergone substantial demographic changes;there was a 71% increase in population between 2001 and 2006 and growthof another 64% in 2011. A noteworthy 80% of new residents since the2006 census have been from visible minorities (Statistics Canada, 2011).To date, few diversity or culturally-related issues have arisen in the home;however, a shift in their resident demographics is considered inevitable(Jovanovic, 2012).

In 2008, the volunteer chaplain resigned after receiving a parish appoint-ment. Considerable tension arose for the home’s administration betweenstakeholder groups when the home’s application to fund a professionalchaplain was refused by the municipality. Spiritual care provision has beencovered by volunteers since that time. Three identified spiritual care vol-unteers with backgrounds in lay ministry visit on a one-on-one basis withresidents and also lead worship-related activities. A lead volunteer sup-ports 18 palliative care volunteers, many of whom attend monthly “ComfortRounds” debriefing meetings with frontline staff.

Resident religious demographics are primarily Protestant, Catholic,Evangelical Christian, or no expressed faith allegiance. Area clergy supportweekly worship and visit congregants living in the home.

Gaps in Spiritual Care at the Study Site

Issues regarding the provision of spiritual care emerged in the project’s2009 environmental scan. There was a general consensus that the provi-sion of spiritual care was inadequate since the volunteer chaplain departed.In 2011, the project’s professional chaplain researcher identified further gapsin the provision of spiritual care:

● Lack of oversight, training, and support for spiritual care volunteers● Concern expressed by family members regarding proselytizing by volun-

teers● Oversubscription of limited spiritual care volunteers resulting in burnout● Internal communications issues, volunteers acting independently, no

documentation of visits, and uninformed about resident deaths● Portering wait times and length of worship services overextended fragile

residents● Lack of training regarding emergent diversity issues for staff and volunteers


Phase 1: Think Tank

In Phase 1, the sample group was a collaborative think tank that includedthe home’s administrator, a spiritual care and a palliative care volunteer,members of the Ontario Multifaith Council (2012), and the project’s chaplainresearcher and knowledge broker. The Ontario Multifaith Council was iden-tified early in the project as a community partner as it is legislated to providesupport in long-term care. Additional concerns emerged through the Phase1 consultation, as follows:

● Recent resident satisfaction survey top concerns: access to privacy andaccess to one-on-one spiritual care;

● Resident end–of-life issues and life review/spirituality issues that gounaddressed;

● Need for specialized volunteer training and support to provide spiritualcare for residents with advanced dementia and for the dying; and

● Forthcoming provincial regulation to govern spiritual care therapeuticinterventions and volunteer scope of practice limitations.

Phase 1 Results

The think tank group decided that a focus group with the home’s spiritualcare and palliative care volunteers was needed to further elucidate volunteerunderstanding of their roles, resources, and need for education.

Co-investigators emphasized the need to structure a formalized researchprocess that included rigorous documentation, ethical approval, and eval-uation so results could be transferrable to other long-term care homes.A literature search was undertaken and a working group included thehome’s administrator, chaplain researcher, knowledge broker, and an OntarioMultifaith Council chaplaincy consultant/trainer. Their tasks were to overseePhases 2 and 3 of the study, in consultation with the co-investigators.

Phase 2: Focus Group

A full needs assessment was conducted with spiritual care and palliative carevolunteers in a focus group luncheon at the home. The sample group forPhase 2 included:

● Four palliative care volunteers;● Two spiritual care volunteers; and● Two volunteers for worship services.

The eight participants were asked about their understanding of theirvolunteer role, to share stories of providing spiritual and palliative care inthe home, to identify the resources they needed, their coping strategies, and


the kind of support of assistance they require. They were also asked aboutthe kinds of education they thought they needed and how it could best bedelivered to them.

Themes From Focus Group Transcript

The transcript from the focus group was assessed using a spiritual caretheoretical perspective. Volunteers demonstrated clear role definition assupportive of residents and their families, especially as death approaches:

I see our role in comforting the resident and family and/or family in theirjourney towards death. Just being there, our presence is invaluable.

They considered their coping skills as quite good: “We’re okay with what wedo or we wouldn’t do it” and they had questions about providing spiritualcare that was respectful and informed regarding other faith traditions:

Maybe a more generalized kind of spiritual training where it wouldencompass all faiths [yeah] would be more beneficial in this day andage is more of a multicultural place than it used to be.

A need for specific spiritual care education was repeated:

More spiritual than religious [yes, that’s it] . . . you are right that kind ofnuts and bolts would be helpful; this will be spiritual care in addition tothe palliative care; Kind of a general social theology [yes, yes] that wouldbe helpful . . . that’s a systems piece that we can um, you know, putforward, that would be helpful; Another resource is courses, I mean wehave all taken courses but after 10 or 15 years it’s time for a refresher . . .offering a spiritual care course . . . because it’s been about 20 years sinceI’ve had mine.

They also expressed concern for recognizing and helping with staff grief:

. . . the staff here has become friends with the residents . . . and thewhole experience for them is traumatic as well; and I think the staff isamazing here, welcoming volunteers no matter what role we are goingfor.

Repeated concern arose over how death is communicated internally in thehome:

That communication piece of who is actively dying or you know,approaching the end, communication around that hasn’t typically beenhappening here; That’s part of our problem too, um, we’ll come in on


a Sunday morning and that person will pass and we won’t know, and itmight have been that very morning, so then it catches us unaware. [yeah]It’s hard, it’s hard, yeah. So you feel like you have been left out.

Phase 2 Results

Analysis of quotes from the transcript demonstrated volunteer requests forsupport from a full-time chaplain, for “nuts and bolts” spiritual care edu-cation, for training in all faiths and cultural diversity, and having morevolunteers and concern over internal communication issues regarding resi-dent death. Two training modules were designed to meet the expressed needof participants in the focus group and items that were previously identifiedas gaps in spiritual care provision.

Phase 3 Training Modules and Evaluation

The training sessions were held one week apart at the home, attended bythree spiritual care and four palliative care volunteers. Of the seven whoattended, 70% also participated in the Phase 2 Focus Group as well.

The first week’s presentation covered “Enhancing Cultural and ReligiousSensitivity, Diversity Issues.” Canadian and local demographic changes,education regarding diversity, power, and privilege were covered along-side non-discrimination policy. Openness to others was stressed withina context of non-proselytization and creating a non-anxious caregiverpresence.

The second week presented on “Volunteer Spiritual Support Skills inLong-Term Care.” The history, meaning and theology of spiritual care inlong-term care were introduced in the context of long-term care regula-tory requirements. Understanding the difference between volunteer spiritualsupport and professional spiritual care was emphasized in the training.

Resident-centered helping skills were taught from the perspective ofclient-centered care (Rogers in Kirschenbaum & Henderson, 1989) and fam-ily systems theory (Friedman, 1985). Self-reflection on ministry practice wasintroduced as a key component of self-care and prevention of compassionfatigue. Volunteer identity in the caregiving team, prayer, and responses togrief and loss were also covered. The proposal for Spiritual Care Circles wasalso presented at this session, in order to ascertain volunteer feedback onhow this may assist them in providing spiritual support for residents.

Phase 3 Results

Expectations of the training were met or exceeded in session two for all par-ticipants and for half of the participants in session one. One volunteer didnot submit an evaluation for the first session. The information presented in


session two was considered organized, meaningful, relevant and well under-stood by all participants. For the first session on diversity issues, participantscommented that they needed more practical information that they couldapply in their volunteering.

Volunteer written responses from the first session regarding impact fortheir future caregiving included:

I think that the training affirmed my practice of the past 20 years.I was trained to be open to all but would like to learn more about otherfaiths.Probably will include more consideration to resident’s spiritual needs.

For the second session, volunteers responded:

More thoughtful before going into a room.More listening and less passing judgment about residents or trying toproblem solve residents issues.Yes, I will approach them more confidently with the information Ireceived in both sessions.

Overall, 80% of the participants were satisfied with the presentationsand comments regarding the Spiritual Care Circle were all positive; somewanted to know how soon it would be implemented for the home.

MODEL FOR SUSTAINABLE SPIRITUAL CARE IN LONG-TERM CARE

Developed out of the phased investigations at the study site, a model issuggested for sustainable delivery of spiritual care in long-term care homes.

The model, as illustrated in Figure 1, relies on three interconnectingelements to provide comprehensive spiritual care for long-term care commu-nities. The model encapsulates the different processes involved: volunteertraining plus regular oversight and support from an internal Spiritual CareCircle, complimented by a community-based Pastoral Support Committee.

Spiritual Care Circle

The design suggested for Spiritual Care Circles (see Figure 2) brings spiritualcare theory and practice together through consultation. Led by a profes-sional chaplain (volunteer or staff), the regular monthly meetings will bean opportunity for trained spiritual support volunteers and staff to examinetheir pastoral encounters with residents. Meetings are held in a “rounds” for-mat to discuss the active caregiving issues that arise for the spiritual supportvolunteers. By instituting regular dialogical explorations of care provided,


FIGURE 1 Training and sustaining model for spiritual care in long–term care.

FIGURE 2 Spiritual Care Circle.

volunteers will deepen their relationships with the long-term care popula-tion, support spiritual and religious needs of residents and their families,and possibly assist as palliation draws near. Having a consistent consulta-tive group that meets regularly and is focused on provision of spiritual careshould meet the need for appropriate volunteer oversight.

Spiritual Care Circles can also support the volunteers with leadershipfrom a professional chaplain and include a measure of self-care for vol-unteers, an aid to volunteer retention (Scott & Howlett, 2009). Ongoingeducation regarding enhanced spiritual care skills could also be offeredat these sessions. This group would be bound by scope of practice,


ethical and confidentiality requirements regarding the residents they providecare for.

The need to assess appropriate boundaries for volunteers is an impor-tant consideration and central to any training provided. Legislation regardingtherapeutic spiritual care interventions in Ontario, Canada, is forthcomingas part of a Registered College of Psychotherapists (Transitional Councilof the College of Registered Psychotherapists and Registered Mental HealthTherapists of Ontario, 2012). Under the Ontario Psychotherapy Act (2007),the practice of psychotherapy (psychologists, chaplains, pastoral coun-selors, family and marital counselors, etc.) will adhere to a competencymodel for registration. This means all who engage in providing spiritualcare psychotherapy, whether working in a volunteer capacity or as a paidprofessional, must hold membership in the Registered College.

Consequently, the model requires a lead professional chaplain whois trained in the kinds of spiritual issues that arise for residents liv-ing in long-term care homes; someone who can respond to volunteersthrough practical knowledge of spiritual care therapeutic interventions andprofessional competency requirements.

Volunteers may still provide spiritual support in a pastoral helping con-text and not require membership in a regulatory body; however, appropriateoversight and support for volunteers is essential. Certified spiritual careprofessionals possess the knowledge, skills, judgment, and experience tofacilitate a spiritual care program, program quality assurance, spiritual careprovision, and ongoing professional development (Canadian Association forSpiritual Care, 2012b).

Bringing both social workers and chaplains together at the table couldbe very workable for municipally funded homes that do not employchaplains. In particular, any resident need for counseling could be identi-fied by the volunteers and brought forward to the social work coordinatorfor psychotherapeutic referral.

The chaplain position on the Spiritual Care Circle is one that could beadvertised for as a volunteer position, so the home would be assured offinding someone who would be well-trained, experienced, and dedicated toparticipation with this group. The home’s administrator would require a linefunction oversight of the chaplain volunteer with a periodic performancereview.

Of course, in homes where chaplaincy is fully funded and part of theinterdisciplinary care team, this model is also a useful means to retain andsupport volunteers active in spiritual and religious care. As issues of reli-gious and cultural diversity arise within long-term care settings, Spiritual CareCircles could actively identify resources for volunteers and staff so optimalcare is provided within the home, care that is respectful of different culturalbackgrounds and faith perspectives.


Volunteer Training

As part of full protection for the public and especially for elderly and vulner-able residents living in long-term care, volunteers require specific trainingfor visiting. The training included in the Quality Palliative Care in Long TermCare toolkit includes three sessions for volunteers which address:

1. History, Meaning and Theology of Spiritual Care in Long-Term Care● Protection of the public and regulatory issues● Model for spiritual care in long-term care● Volunteer identity in the caregiving team

2. Building Spiritual Caregiving Skills for Volunteers● Family systems theory and client-centred care● Visiting ministry skills (active listening, empathy, prayer)● End-of-life issues for long-term care residents● Compassion fatigue and self-reflection on ministry practice

3. Culturally Sensitive Care and Communications● Power differentials● Faith/cultural fact sheets

Pastoral Support Committee

In most long-term care homes, area clergy are active in leading worshipservices and visiting their congregants who live in the home. Communitysupport for the religious and spiritual care needs of long-term care residentsmust also be coordinated for the overall delivery of effective spiritual care.

The Pastoral Support Committee is a community-based group that pro-motes inclusive spiritual and religious care for the home’s residents andfamily members. It is comprised of a resident from the home and the LifeEnrichment Supervisor, spiritual care volunteers who lead regular worshipservices as well as representatives from the local faith communities, includ-ing clergy and pastoral care providers. The volunteer professional chaplainmay or may not participate, depending upon his or her level of involve-ment, and the staff chaplain certainly would participate. The Pastoral SupportCommittee is accountable to the home’s administrator.

In the study site home, a special effort was made to include visibleminorities and diverse faith expressions, in recognition of local demographicchanges. Also, the designated Ontario Multifaith Council regional managerparticipates to further guide diversity awareness in the home. This groupmeets quarterly and is chaired by a member of the local ministerial group.

The Pastoral Support Committee could be an effective source for recruit-ing new spiritual support volunteers from the community. These volunteers,once trained, would increase the number of one-on-one spiritual support


visits with residents and also receive support and oversight through theSpiritual Care Circle. Pastoral visiting in faith communities would also benefitfrom members trained in spiritual care. It is hoped that these three differentcomponents—volunteer training, the Spiritual Care Circle, and the PastoralSupport Committee—will provide long-term care homes with comprehensivespiritual care for their residents.

DISCUSSION

The phased investigative process of this research was in itself a kind ofself-reflection on spiritual care practice in the study site long-term carehome. By engaging stakeholder voices in interviews, think tank consultation,focus group and evaluation of formalized training, a praxis/theory/praxishermeneutic was invoked.

The data gleaned from this process yielded a clearer understandingof the gaps in spiritual care provision at the long-term care home. It wasimportant that volunteers themselves were engaged through a formalizedresearch process to identify what they saw as needed for spiritual care in thehome. Feedback from the focus group and thematic analysis of the transcripthelped to create training that was undergirded by the spiritual care theolog-ical framework. Participants in the Spiritual Care Skills and Diversity trainingappreciated the practical skills and education about the history, theory, andtheology of spiritual care. They requested more information regarding spe-cific faith and cultural issues for long-term care. The Spiritual Care Circle wasreadily understood by participants.

Spiritual Care Circles as Best Fit for Long-Term Care

The “rounds” approach is a familiar and effective model in care-providinginstitutions such as hospice and acute care hospitals. The study site alreadyhas good experience integrating its palliative care volunteers in their monthlyComfort Care Rounds.

As many volunteers are attracted to pastoral work because of their ownfaith values, ongoing education with a professional chaplain will eliminateany hint of religious proselytization. Better understanding of the care theyare providing will also aid in referrals for counseling and support expressedresident need for one-on-one spiritual care more effectively. The SpiritualCare Circle will also minimize risk to residents and ensure full protectionfor their privacy. They are a vulnerable population and may share personalinformation while discussing their end-of-life issues.

Volunteers may gain appropriate oversight and support, which encour-ages volunteer retention and better understanding of their role. They willalso be encouraged to practice self-care. Training can protect volunteers from


going beyond regulatory and scope of practice boundaries regarding spiritualcare therapeutic interventions. Professional staff involvement in the SpiritualCare Circles will also help identify referrals for residents who may needpsychotherapeutic counseling. This paradigm may also be implemented inmunicipalities that are experiencing rapid demographic changes; being ableto meet the spiritual care needs of visible minorities may pose a challengefor some communities.

Having a close link to local faith communities through the PastoralSupport Committee can keep the long-term care home current with freshvolunteers who can also make use of the long-term care training to work intheir own parish visiting programs. The inclusion of diversity awareness willhelp overall integration in the community for visible minorities and hopefullyminimize cultural misunderstandings in the long-term care home.

Limitations

In Ontario, Canada, privately funded and faith-based long-term care homesgenerally make provision for chaplaincy. The Quality Palliative Care in LongTerm Care research (Palliative Alliance, 2013a) has demonstrated that fund-ing models for long-term care homes in Ontario has left some municipalitiesin a position of having to choose between having a social worker or a pro-fessional chaplain. The northern study site homes are faith-based and havechaplains on staff; however, they struggle with aspects of providing socialwork, while the opposite was found in the two southern study site homes.

The Spiritual Care Circle requires a professional chaplain as volunteeroversight and support needs to reflect the ideology and ethical practiceof spiritual care in long-term care, something professional spiritual careproviders are trained to do. It is hoped that through the volunteer contribu-tion of a professional chaplain’s time, municipally managed long-term carehomes may be able to provide for the spiritual care needs of their residents,although this is not the ideal.

The model is exclusive of staff needs for spiritual care and support,something which the staff of this study site were accustomed to with theirformer volunteer chaplain. Also, there is no chaplaincy presence on the inter-disciplinary care team; in acute care institutions, spiritual care involvementin interdisciplinary care is a proven commodity (Burkhart et al., 2011; Nolan,2011; Bursell & Mayers, 2010; Mowat et al., 2010; Pesut et al., 2012; Carey &Davoren, 2008; Atchley, 2008; Austin, 2006; VandeCreek & Burton, 2001).

CONCLUSION

A practical toolkit for use in long-term care homes was created using aSpiritual Care Circle, volunteer training and a Pastoral Support Committee as


an inter-functioning model to assist long-term care homes (especially thosewith no funding for a professional chaplain) to provide spiritual and religiouscare for their residents (Palliative Alliance, 2013b). This spiritual care sub-study was looking for a “direct practice intervention” (Netting, 2010) thatwould be responsive to the identified gaps in spiritual care for the group towhom this mattered the most—the long-term care residents. In attending tothe beliefs, values, and observations of current spiritual care and palliativecare volunteers in the home, a capacity development initiative based uponspiritual care ideology, ethical, and regulatory considerations endeavored tomeet their expressed needs. The training provided for volunteers as partof this research made clear delineation between what a spiritual supportvolunteer offers for residents and what a professional chaplain can provide.

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